RU2408294C2 - Method of cholecystectomy from mini-access - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be used for cholecystectomy from min-access. Before operation under ultrasonic control two points are marked on anterior abdominal wall: place of hepaticocholedoch or portal vein projection at the level of hepatoduodenal ligament on the one side and bile bladder bottom on the other side. Maximally close to marked points transversal cut of skin, subcutaneous fat, anterior wall of rectus sheath is performed. Medial part of rectus with separation from posterior sheath wall is isolated and transected with preservation of large vessels and nerves. Posterior wall of rectus sheath with peritoneum is cut across. Sheets are sutured to transected posterior wall of rectus sheath and peritoneum. Counterpuncture is made through which bile bladder is pulled off by means of clamp with further introduction of drainage.

EFFECT: method allows to minimise trauma of abdominal wall, reduce operation duration.

2 ex

Description

The invention relates to medicine, in particular to surgery.

It was developed in the hope of widespread use in the surgical treatment of almost all clinical forms of cholelithiasis. It requires inclusion in recent operations of small accesses, sparing surgery, minimally invasive surgery.

To date, 3 main technologies for operating patients with various forms of cholelithiasis have become generally available:

- traditional cholecystectomy (Guide to surgery of the liver and biliary tract. 2 volume, Edited by prof. A.E. Borisov, pp. 39-44);

- video laparoscopic cholecystectomy. (Guidelines for biliary tract surgery. Edited by E.I. Galperin, P.S. Vetshev, pp. 163-175);

- cholecystectomy from mini-access. (Manual on biliary tract surgery. Edited by E.I. Galperin, P.S. Vetshev, pp. 176-183).

Traditional cholecystectomy can be performed through the upper median laparotomic approach or from an incision in the right hypochondrium according to Kocher. Other accesses (S.L. Fedorov, Sprengel, Rio Branca, etc.) are currently not applied. In planned and emergency surgery, the upper median laparotomy is often used, sometimes with a continuation downward with a bypass around the navel on the left. In the presence of infiltrate, with technical difficulties in people with hypersthenic type, an oblique hypochondrium is considered more convenient. The main disadvantage of Kocher access is injury. The upper median laparotomy is performed by layerwise dissection of tissues along the midline from the xiphoid process to the navel and below. The skin, subcutaneous fatty tissue, white line of the abdomen, parietal peritoneum are dissected.

When accessed by Kocher, the incision is made in parallel and below the right costal arch by 4-5 cm. After dissection of the skin and subcutaneous tissue, the front wall of the vagina is opened with the rectus muscle crossed in the transverse direction. On the medial side, an aponeurosis of the white line of the abdomen is dissected. In the lateral direction, the aponeurosis of the external oblique muscle of the abdomen is opened to the level of the lateral angle of the wound of the abdominal wall. The rectus muscle is crossed with the application of Billroth's long clamps and bandaging of the stump with absorbable suture material. The fibers of the internal oblique muscle of the abdomen are bred bluntly along the fibers, if necessary, the edge of the external oblique muscle is crossed. Dissect the posterior wall of the vagina of the rectus abdominis muscle transversely with the parietal peritoneum. Napkins are fixed to the parietal peritoneum. Then the exposure is created with large operational hooks. There are two methods of cholecystectomy “from the bottom” and “from the neck” (antegrade or retrograde cholecystectomy).

Retrograde CE begins with the isolation and ligation of the cystic duct and cystic artery. When antegrade ChE begins with the preparation of the gallbladder from the bottom. The technique of traditional cholecystectomy is recognized as safe as possible, especially with severe inflammatory or cicatricial changes in the region of the Kahlo triangle and hepatoduodenal ligament.

The disadvantages of the method:

- significant trauma to the structures of the anterior abdominal wall and innervation of the muscles of the anterior abdominal wall, a significant number of early and late complications, in particular postoperative ventral hernias;

- operational trauma of moderate severity, leading to an increase in the catabolic phase p / o period, impaired external respiration, paresis of the intestine, limiting the physical activity of the patient;

- a significant cosmetic defect;

- a longer period p / o rehabilitation and disability.

Video laparoscopic cholecystectomy:

This technique involves CE without opening the abdominal cavity. There are two main ways: American and French, differing in the location of the operator in relation to the patient, the places of introduction of the trocars. One principle - the creation of pneumoperitoneum, removal of the gallbladder using special manipulators, a laparoscope without opening the abdominal cavity. The disadvantage of LCE is the presence of circumstances that impede its implementation. The so-called absolute and relative contraindications are absolute contraindications:

1) Destructive cholecystitis with dense perivesical inflammatory infiltrate or diffuse peritonitis.

2) Acute cholecystopancreatitis on the background of choledocholithiasis.

3) Malignant tumors of the hepatopancreatobiliary zone.

4) Biliodigestive and bilobiliary fistula.

5) Congenital malformations of the gallbladder and extrahepatic bile ducts.

6) Late pregnancy.

The closest is cholecystectomy from minimal access using a set of tools "mini-assistant" according to M.I. Prudkov (Manual on biliary tract surgery. Edited by E.I. Galperin, P.S. Vetshev).

This operation involves a small section of the abdominal wall and the creation of a much larger area in the abdominal cavity, accessible to adequate examination and manipulation. The “mini-assistant” set is represented by a ring-shaped retractor, a set of mirror hooks, and a lighting system. With the help of a special mechanism for changing the angle of inclination of the clamps, an adequate exposure is created when the abdominal wall is cut 3-5 cm long. In this case, the abdominal wall incision is performed by retreating 2 transverse fingers to the right of the midline, starting from the costal arch, vertically downward, 3-5 cm long.

Contraindications to cholecystectomy from mini-access:

- the need for revision of the abdominal cavity;

- diffuse peritonitis;

- uncorrectable coagulation disorders;

- cirrhosis of the liver;

- gall bladder cancer.

The disadvantages of the prototype are:

- the need to have in the arsenal a special set of tools "mini-assistant";

- long installation time of the hook-mirror system and lighting - open laparoscopy;

- it is not always possible to install the mirrors correctly, achieving complete fixation of the early expander, adequate lighting in the subhepatic space;

- a constant incision 3-4 cm to the right of the median line does not always allow you to go to the place of surgical intervention.

The objective of the invention is: reducing the duration of the operation, the ability to perform operations without special tools, minimizing trauma to the abdominal wall without increasing pressure in the abdominal cavity.

The essence of the invention lies in the fact that in the preoperative period with ultrasound of the liver, gall bladder, pancreas, two points on the anterior abdominal wall are noted: the projection site of the hepaticoholedoch or portal vein at the level of the hepatoduodenal ligament on the one hand and the bottom of the gall bladder on the other hand.

The surgical procedure is as follows:

Parallel to and below the costal arch on the right, a few centimeters from the midline in the intermediate position, as close as possible to the selected points, a skin incision is made and s / c 4-5 cm long.After opening, the third section of the rectus sheath is opened in the same direction in the direction of the vagina. The selection is carried out from the white line of the abdomen by separating the rectus muscle with the finger from the back wall of the vagina. If there are large vessels (a. Et v.epigastrica superiores) and nerves in the secreted “muscle bundle”, they are shifted to the side. Muscles intersect with an electric knife or at clamps. If all the points are observed, the zone of operational impact opens well, while maintaining a strong abdominal cage. Dissected back wall of the vagina and peritoneum are sheathed with linen. A hook with a illuminator is inserted into the abdominal cavity, which is most often used to divert the right lobe of the liver.

The area of the gallbladder and hepatoduodenal ligament is limited to surgical napkins with long “tails” of thick lavsan ligatures. They are introduced into the abdominal cavity completely and installed between the mirrors, as in traditional cholecystectomy: left - under the left lobe of the liver, left and down - to divert the stomach and large sebaceous, right and down - to divert the hepatic angle of the colon and loops of the small intestine.

Cholecystectomy itself differs from traditional cholecystectomy in the need for distant surgery and the inability to enter the arm into the abdominal cavity. When tightening the nodes, Vinogradov’s wand is used, and the gallbladder is pulled back by a soft long clamp inserted through the counter-hole, through which the drainage tube is subsequently held. Transverse access, performed taking into account the localization of hepatic choledochus and gall bladder, and the use of the above techniques allows you to operate under good visual control.

The basic rules for performing cholecystectomy are as follows:

- clearly distinguish hepaticoholedoch and cystic duct from the neck of the bladder to the confluence of the bile duct;

- bandage the cystic artery after its clear identification, then the cystic duct;

- with a pronounced inflammatory process with cicatricial dense adhesions and the inability to verify anatomical structures that require processing, after 30-40 minutes they switch to TCE with access according to Kocher. Then the gall bladder is isolated from the bed from the neck or from the bottom by any known methods. The operation ends with the installation of perforated silicone drainage to the bed of the gallbladder through contraception. At the same time, the end of the drainage tube is slightly led into the Vinslovo hole. The wound of the abdominal wall is sutured in layers tightly.

Clinical example 1

Patient X., 36 years old, was admitted to hospital №2 of the Republican Clinical Hospital of the city of Nalchik with a clinical hospital. Acute calculous cholecystitis.

The department examined clinically and laboratory:

OAK - er. 3.6 · 10 ¹² , Нb - 132 g / l. CPU - 0.89, lake. - 9.6 · 10 ⁹ , p - 8, s - 73, l - 15, m-5, ESR - 22 mm / h.

OAM - color - w, transparency - incomplete., Beats. weight 1020, reaction - acid., flat - units. in s / s, lake. - 5-6 p / z, er. - 4-5 in the salary.

Bilirubin - 20.5 mmol / L, total protein - 70.0 g / L, creatinine - 98 mmol / L, urea - 4.8 mmol / L,

ECG: sinus rhythm with heart rate - 64-78, sinus arrhythmia. The electrical axis of the heart is deflected to the left, signs of left ventricular hypertrophy.

FEGDS - conclusion: superficial catarrhal gastroduodenitis, reflux esophagitis, indirect signs of pancreatitis.

Ultrasound of the hepatoduodenal zone - conclusion: cholelithiasis. Calculous cholecystitis. Reactive pancreatitis.

The patient was operated on: a cholecystectomy from mini-access was performed. Surgical finding - acute calculous cholecystitis.

In the postoperative period received antibacterial and infusion therapy. The drainage tube was removed on the 1st day after surgery. A cosmetic skin seam was removed on the 7th day.

The patient was discharged in satisfactory condition on the 7th day after the operation.

Clinical example 2

Patient S., 42 years old, was admitted to hospital No. 2 of the Republican Clinical Hospital in Nalchik with a clinical hospital for chronic calculous cholecystitis.

The department examined clinically and laboratory: KLA - er. 4.1 · 10 ¹² , Нb - 133 g / l. CPU - 0.9, lake. - 11.7 · 10 ⁹ , p - 10, s - 71, l - 22, m-1, ESR - 36 mm / h.

OAM - color - s / f, transparency - incomplete., Beats. weight 1030, reaction - acid., flat - units. in s / s, lake. - 8-9 in p / z, er. - 2-3 p / s.

Bilirubin - 24.5 mmol / L, total protein - 65.0 g / L, creatinine - 103 mmol / L, urea - 5.2 mmol / L,

ECG: sinus rhythm with heart rate - 96, sinus tachycardia. The electrical axis of the heart is deflected to the left, incomplete blockade of the right leg of the bundle of His, signs of hypertrophy of the right atrium and left ventricle. Diffuse changes in the myocardium.

FEGDS - conclusion: superficial erosive gastritis, reflux esophagitis, indirect signs of biliary tract pathology. Ultrasound of the hepatoduodenal zone - conclusion: ZhKB. Calculous cholecystitis. Merisi's syndrome. Reactive pancreatitis.

The patient was operated on: a cholecystectomy from mini-access was performed. Operational finding: calculous cholecystitis. The calculus of the Hartmann pocket.

In the postoperative period received antibacterial, infusion and symptomatic therapy. The drainage tube from the subhepatic space was removed on the 2nd day after surgery. A cosmetic skin seam was removed on the 7th day. The wound healed first.

The patient was discharged in satisfactory condition on the 8th day.

Clinical example 3

A 42-year-old patient was admitted on an emergency basis with a diagnosis of cholelithiasis. Acute calculous cholecystitis, choledocholithiasis? Obstructive jaundice?

After preoperative preparation, the patient was operated on. Produced cholecystectomy from mini-access, choledocholithotomy, drainage of the common bile duct according to Vishnevsky.

At the time of admission: general condition of the patient of moderate severity, conscious; complaints of intense pain in the right hypochondrium, which appeared against a background of aching pain.

Objectively: respiration in the lungs is weakened vesicular, no wheezing; NPV - 18 per min.

Heart sounds are muffled, rhythmic, heart rate 96 per minute. HELL 100/70 mm Hg

The tongue is dry, coated at the root with a white coating. The abdomen is moderately swollen, painful in the right hypochondrium on palpation. Symptoms of Kocher, Lepene, Ortner positive. There are no symptoms of peritoneal irritation. Intestinal motility is sluggish. The chair is acholic. Urination without features.

On examination:

Ultrasound of the hepatoduodenal zone: calculi of the gallbladder 15-25 mm in diameter. Concretions of the common bile duct, signs of reactive pancreatitis. The patient was discharged on the 12th day after surgery in a satisfactory condition.

The technical result achieved by the invention:

- low invasiveness of the operation;

- adequate access to the gallbladder and common bile duct through the shortest distance;

- the ability to manipulate the biliary tract in an adequate volume;

- lack of pneumoperitoneum;

- the ability to perform surgery in late pregnancy;

- the absence of impaired respiratory function, intestinal paresis, reduced need for analgesics, early recovery of motor activity;

- quick training of specialists in the operating technique.

At the same time, problems arising when using the “mini-assistant” are also solved. This is a practical lack of need for special tools; choosing the shortest distance to the place of operation before the operation, quickly creating adequate access to the area of the operation with the preoperative “optimus” calculation for visual convenience, reducing the number of instruments in the laparotomy wound by using contra-counting, reducing the time of operation due to the absence of the need to install a hook system.

Claims (1)

Method of cholecystectomy from mini-access, including an incision in the skin, subcutaneous adipose tissue, anterior wall of the rectus sheath, rectal muscle separation, dissection of the posterior wall of the rectus sheath and peritoneum and their fixation, removal of the gallbladder, characterized in that before the operation is under control Ultrasound marks two points on the anterior abdominal wall: the projection site of the hepatic choledochus or portal vein at the level of the hepatoduodenal ligament on the one hand and the bottom of the gallbladder on the other hand, is performed as close as possible to the At these points, a transverse incision of the skin, subcutaneous fatty tissue, and the anterior vaginal wall of the rectus muscle, secrete the medial part of the rectus muscle with separation from the posterior wall of the vagina, cross it with preservation of large vessels and nerves, cut across the posterior wall of the vagina of the rectus muscle with peritoneum, to the dissected posterior Sheets are hemmed to the rectus sheath wall and peritoneum, contra-holes are performed, through which the gallbladder is pulled back with a clamp, and then drainage is introduced.